AI-Assisted Clinical Documentation: A Comprehensive Design Model for Automating Clinical Notes

Abstract

The integration of Artificial Intelligence (AI) in clinical settings is revolutionizing how medical documentation is handled. Healthcare professionals spend considerable amounts of time on manual documentation, which can detract from patient care. This paper presents an extensive design model for an AI-assisted clinical documentation system that captures and processes interactions between medical professionals and patients, generating structured clinical notes through advanced Natural Language Processing (NLP). The system ensures compliance with medical standards, offers revision capabilities before submission and integrates seamlessly with Electronic Health Record (EHR) systems. This approach significantly reduces administrative burdens, minimizes documentation errors, enhances the quality and accessibility of medical records, and streamlines medical workflows. Keywords — AI in Healthcare, Automated Note Generation, Clinical Documentation, Electronic Health Records, Healthcare Automation, Machine Learning in Medicine, Medical Informatics, Natural Language Processing.